Cycle 1
Health 2024-06-20 · Fire 2024-06-20
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Olathe, KS
Nottingham Health And Rehabilitation
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
14200 W 134th Place, Olathe, KS
(913) 322-3111
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-04-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.15
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.09
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.76
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
6.32
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,660
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0099
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.37% · Performance 22.65% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.07
Baseline 5.87% · Performance 6.92% · Measure score 3.07 · Achievement 3.07 · Improvement 0
Total nurse turnover
8.91
Baseline 57.41% · Performance 27.27% · Measure score 8.91 · Achievement 8.91 · Improvement 8.76
Adjusted total nurse staffing
10
Baseline 5.01 hours · Performance 6.12 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.77% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 5.23% · Lower 95% interval 6.25% |
| Discharge to community | 55% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 164 · Observed rate 53.05% · Lower 95% interval 46.38% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 141 · Denominator 141 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 141 |
| Discharge self-care score | 50.46% |
53.69%
3.2 pts worse
|
Numerator 55 · Denominator 109 |
| Discharge mobility score | 50.46% |
50.94%
0.5 pts worse
|
Numerator 55 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 1.42% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 141 · Adjusted rate 1.79% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 5.69% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 1.9% |
8.2%
6.3 pts worse
|
Numerator 3 · Denominator 158 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 62.39% |
56.45%
5.9 pts better
|
Numerator 68 · Denominator 109 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 29 · Denominator 30 |
| Transfer of health information to patient | 98.82% |
96.28%
2.5 pts better
|
Numerator 84 · Denominator 85 |
| Resident COVID-19 vaccinations up to date | 37.66% |
25.2%
12.5 pts better
|
Numerator 29 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.8
1.5 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.2
1.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
4.4%
0.6 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.8% · Q3 5.4% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
5.6%
5.1 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.0%
3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 3.9% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
23.2%
3 pts better
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 20.0% · Q3 18.5% · Q4 22.6% · 4Q avg 20.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
19.8%
19.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.2% |
18.4%
4.2 pts better
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 15.5% · Q3 0.0% · Q4 23.0% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
18.8%
0.9 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 24.0% · Q3 16.7% · Q4 26.4% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
23.2%
0.3 pts better
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 44.3% · Q3 13.7% · Q4 16.7% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.6%
0.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.5% · Q3 6.8% · Q4 4.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
75.6%
24.1 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.5% · Q3 99.5% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
11.7%
5.4 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
73.5%
23.5 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
23.0%
6.4 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 14.3% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-04 · Fire 2022-10-04
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-05-20 · Fire 2021-05-20
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-20
F · Potential for more than minimal harm
2024-06-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-06-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-20
F · Potential for more than minimal harm
2024-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-20
F · Potential for more than minimal harm
2024-06-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-20
E · Potential for more than minimal harm
2024-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-06-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-20
E · Potential for more than minimal harm
2024-06-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-14
F · Potential for more than minimal harm
2022-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-04
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-04
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-04
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-23
F · Potential for more than minimal harm
2021-05-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-05-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-05-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-06-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-20
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-15
E · Potential for more than minimal harm
2022-10-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-11-04
E · Potential for more than minimal harm
2021-05-20
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-06-09
E · Potential for more than minimal harm
2021-05-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-06-09
E · Potential for more than minimal harm
2021-05-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-06-09
Penalties and ownership
What sits behind the stars
Ownership
Axiom Healthcare Alliance, LLC
5% Or Greater Direct Ownership Interest · Organization
Lakin, Gregory
5% Or Greater Indirect Ownership Interest · Individual
Wichita Wellness Inc
5% Or Greater Indirect Ownership Interest · Organization
Axiom Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Hermes, Frederick
5% Or Greater Indirect Ownership Interest · Individual
Lillie, Matthew
5% Or Greater Indirect Ownership Interest · Individual
Matt Lillie Investments, Inc
5% Or Greater Indirect Ownership Interest · Organization
Evans, Roger
5% Or Greater Indirect Ownership Interest · Individual
Roger Evans Revocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Dennis L. Ross Pod To Trustee Of Dennis L. Ross Living Trust U/A 4/4/1
5% Or Greater Indirect Ownership Interest · Organization
Ross, Ann
5% Or Greater Indirect Ownership Interest · Individual
Ross, Dennis
5% Or Greater Indirect Ownership Interest · Individual
Axiom Healthcare Services LLC
Operational/Managerial Control · Organization
Barbeau, Brian
W-2 Managing Employee · Individual
Becnel, Chance
Corporate Officer · Individual
Kruse, Brenda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Colonial Village
Overland Park, KS
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Stratford Commons Rehab & Health Care Center
Overland Park, KS
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Villa St Francis Catholic Care Center Inc
Olathe, KS
5-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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